Mecklenburg_Well Abandonment_20231122 (16)

WELL ABANDONMENT RECORD FarinicmdUscoNLY:
This fbimcati be ut ed.for sin&or mulliplz wells
I.Well Contractor information: WELL ARANDONMENT DF:TAt1-.S
Each Thompson 7a.Niimber of n•ells being alrondlonlcrl: 1
lYeltCoibmetorKari�C(4t�celtarr personally:atra�frin[iJettnll.ouliisilsrpmVesty) �w' nJJrluPk liveLvair a• Ron-iw�cr supph 'wells .Q.VLY utrlr ilk saua
cods(n(coowaban do)FIN M4)YJr1 CWT sJ+r.uul wie firm.
9478A
NC Well Coal>aGorCcftity rLau Nnn>bcr 7b.Anriiti:imate volume of trot�'I muluini;in yrell(ti):
SAEaACCo FOR%.rATFR.SSIJPPI,1'lVFLt. ONLY:
Cate pool Nam: 7c,Type of disinfectagt used: I.
I
2:Well Construction Permit N:. ,
Lr31 ir11 nppfttit6fe iiefl yu itiiy tie_tuaf4v.Ste ,varjawe.liffedfurt,;eft-4 Offiwu
7d.."unt ofdisinf4't'ta4t use&
3.Wd6 u� (clad:n ell iirej:
Water Supply Well: 7e.Sealing rnateridls used(Cb.04-all that apply):
❑Aariciiltuial pTvliuiicip711Qtililic W.Neat Ccniciit.C.rtz?ut 13 Hcr4onitc Chips orPOIcts.
DOwthermil(Hca ftlCopling$apply) ❑Sm d Cement Cmut E3 My C v
❑bdustrial/Comnicrcial ❑Rcsideutfid Water Supply(strand) ❑,Concrote Grout ❑ Drill Cuttings
•❑lni tioo 0. -Specialty Grow b Gratei
Ron 1YsterSupplvWcil; d Betitottite Slgtri ❑Oihcr(esplairtuoder 7g)
Monitoring- gRecoveiy
Iajcctian`Vcll: 7f For each uiaterial-sclectedaboce,provide awounraf.materiatsitsed:
❑Aquiferltcdrarge` ❑Gruwuitiiier-ltemediatiotf Neat Cem.:i881b ,Wtr:124al. Sand-Cem:•lb ,Wtr:gal.
DAquiferSionige uiai M-pveiv. ❑Sulitdty DarrleP
❑AtluifcrTc'st ❑SloinntvterUt:ilrirgc Bentonite cement Amount:10 galls
❑Egierintentul Tccltcm[okn ❑Subsldettce Coiiunl 7g.Prriiid.L a liricf d6criptiaii af,thc'al)Aftdnumcnt prN&duitf
OGeothermat(GlosedLoop) 011racer
❑Geothermal(Heiid! COollu&Return) 130ther(es lainundcr7a}.
Injection through trim9.e pipe
is •,
4.Datcwell(s)ahandonctit 11-8-23 i ?..• �,;,' sd>rb
zs
NOV 2 M'�
5a.1Yrt1 taealloq: 7092—
Clariant.Mt Holly East Facility
P.1cilil ID f�ppli�blsl S:.Certilleatiou:
Facilitc/Urvixt Nmnc v 9 , `.
11701 Mt.-Holly Rd'. Charlotte, .NC �_ 11/9/2023
Plt}ascot Addn s;Ciiy grid Zip Sir�lr.,e:f 4eriilioct.will i awraelni or 1VC11 C�cnvr U,ue
Mecklenburg IJS vJ JIrJ��this fa .f hembv certrf­dw!the uvelift)wav fivere)abtmdoned sit
county. Parcd ld,,Ailtcit)nri No.(PI LVj aces nfalrce ll itlt f5 f;4 IC Qi�C,_QIOfJ,ur 2L _U2[}0(G�lt Ctitialruc(la»Strait&rrcls
and thus'aceppofthisrccurdlmbe;ve.protiir'edto7he.ti 11citv)ien--
Sh: ;ttiladcatid lnnfiiitttritc:in.d6recyfitlnineslsccnnds.ard00m;il degtccs:
(ir'.W11 AM,our 9.She diitgrant or additioual well'details:
You.euay.usa de back.bf this p�tg8 to pt6vids:additional uvUAite.dcrails•oi well
abaudonmrrni details:You ipv u6s :utacli a tditioual6a of if necessaty.
e(M fRE1CG ON-DETA1ILS OF LVELOS)SLING AlfANDONED SiLM-MMAL iNSTRUCTi0N5
Afbdi Hell evr,A•tnrceitut n[cvrl/sJ'J�ai trarile Frig prulriplr itl�ctirLe;rrr r�rn.rrutar sriipplJ' b
n-efte 61iy v'tfh wte fti ltt. 10.,4 Tar All Wells:- Submil this fomi'trithiu 30 days,of completion of itrll
Ga.R'clI IDa: -9 abandonment to the follow1ki; I;
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©ivision of�VaterResourtm,information-Prace_imng Unit;
Gb.Totat well depth: 63 (ft} I617 mail Suniec Ccutec,Raleigb,NC 27699-160
10b.P'nr lnlize I an W-11: In add[ti6a to seudiug ilia tact to the address W l0h
Gc.Bnecttole diameter:a ubovc,also subadt one copy,of this torn t%A6 30 days of convIetion of well
(iu:} ab&fd6uutcut to the follottitii a
6t 1 : 31 .Dltilsigrt.af WaterResoariesi, dergr'uund iltleat6u Cancrol Prog"itu,
6.Water cvcl.bc[ott•gttiund sarfuca. �(ft.) 163(i lllail Scn•icc('�ritct;Natci�h,lliC 2;5'79-t535
1((c-ine iVarar Stinnla.cc infi fonyWelly: In additian td sending the fomr to
CW—Outcr casing Icngtir.(if lmntrn); . (ft) the-address(es).aboie, also submit.one copy of this toots Within 30 days of
completion of well abandurunent to the county hebtlii depatuueut of the counts,
Gf.toner casim;JhiUina tcuydh(if I,yratrn): M.)
tidun ab indoncit.
i
G",smvn levy tti(if lwott n)s A)
knu GW-30 Nonh Caro[lin DcpaWrb of Emiroarm_nt and Natural Resouncs-QIvision of Watcc pelso lugs Revd August 2013
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